Knowledge and management of female genital schistosomiasis in sub-Saharan Africa: A scoping review protocol

Background Approximately 20 to 120 million women of reproductive age worldwide are thought to be affected by female genital schistosomiasis (FGS). It is a preventable manifestation of schistosomiasis in adolescent girls and women, which remains underreported, underdiagnosed, or misdiagnosed, and largely untreated. Objective This study aimed to map evidence on the knowledge and management of FGS from 1950 to 2022 in sub-Saharan Africa. Method The Arksey and O’Malley and Levac et al. framework suggestions and a guideline from Joanna Briggs Institute will be employed. Search for literature will be in PubMed, Scopus, Cochrane, Web of Science, MEDLINE via PubMed, and Google Scholar from 1950 to 2022 for useful published research articles using key phrases or search terms and grey literature with limitations for studies conducted in sub-Saharan Africa. Two reviewers will screen the articles. Kappa coefficients by Cohen statistics will be computed for inter-screener agreement, and the selected articles will be evaluated using Mixed Method Appraisal Tool (MMAT). Results The researchers will map and explore the evidence of the knowledge and management of FGS in the subregion. The years of publications, countries of study, and settings will be reported, and the identified research gaps will be reported. Conclusion The researchers anticipate that this study will determine and map the evidence on the knowledge and management of FGS in sub-Saharan Africa; identify knowledge and management gaps, and direct future research. Contribution This study will add to the literature on FGS and direct future research regarding the knowledge and management of FGS.


Introduction
Schistosomiasis is a debilitating tropical disease ranked third after malaria and intestinal helminthiasis in terms of its occurrence. 1,2The disease is caused by trematode parasites of the genus Schistosoma, which people contract through direct skin contact with infested freshwater during routine activities such as agricultural, domestic, occupational and recreational activities. 1 Human beings are affected by 6 out of the 24 species.However, of the six species, S. haematobium, S. mansoni and S. japonicum are the most common species. 3Hybrid between animal and human species is increasingly recognised as human pathogens.Whereas intestinal schistosomiasis is caused by S. mansoni and S. japonicum, urogenital schistosomiasis is caused by S. haematobium. 4pproximately 240 million infected individuals with 3.3 million disability-adjusted life-years have been documented worldwide, and over 90% of the infected individuals live in sub-Saharan Africa. 2,5,6About 105.4 million received praziquantel treatment out of the projected 236.6 million susceptible individuals in schistosomiasis-endemic areas in 2019. 2 Female genital schistosomiasis (FGS), a clinical expression of S. haematobium caused by the implantation of parasitic eggs in adolescent girls and women's genital tracts, affects approximately 20 to 120 million women and girls globally. 7,8,9,10Gyapong and Theobald asserted that this projection might not accurately reflect the global impact of FGS. 9 Historically, FGS was first reported in 1899 in Egypt; other reports surfaced in the early 20th century, and others have followed into the present century. 11,12,13,14,15However, FGS continues to be poorly recognised, misdiagnosed, underreported and often untreated. 7Female genital schistosomiasis is often unrecognised early and affects the same populations that are most severely impacted by cervical cancer and human immunodeficiency virus (HIV) globally. 16,17,18,19It is an example of the difficulties women and girls encounter as they deal with numerous and interconnected health, sociocultural, environmental and economic issues. 7olposcopy can be used to identify painful vaginal lesions, which include grainy and homogenous yellow sandy patches, rubbery papules and aberrant blood vessels. 13,20,21Other symptoms include spotting, often combined with abnormal discharge, which can be stigmatising as dyspareunia (coital pain or general discomfort and pain during sex). 7,8,22These symptoms are synonymous with sexually transmitted infection (STI); thus, FGS is rarely considered among women who report to health facilities with such presentations, even in schistosomiasis-endemic communities. 9,23Female genital schistosomiasis has often been misdiagnosed as STI because of its syndromic presentation and inadequate knowledge of the disease among healthcare workers. 23,24,25male genital schistosomiasis damages the reproductive system, resulting in infertility, ectopic pregnancy, miscarriages, premature babies, small or gestation-age babies and maternal death among other clinical consequences. 22,26,27,28he disease raises the risk of developing cervical cancer 29,30,31 and HIV by three times, 17,19,32 which is biologically plausible.There is a dearth of literature and information on stigma and discrimination connected to FGS.The pain that FGS causes among women of reproductive age is avoidable by diagnosing them at an early age and providing them with frequent praziquantel medication throughout their lifetime. 22Another challenge with FGS is how to diagnose it.Although the World Health Organization (WHO) FGS pocket atlas simplifies FGS diagnosis, tools and skills, for example, colposcope devices are unavailable at the primary healthcare levels where most cases are usually seen. 20,33e change of the name of the disease from urinary schistosomiasis to urogenital schistosomiasis by WHO was to increase and improve awareness and emphasise the effect on the genital tract. 34Despite these efforts, studies have reported inadequate knowledge and skills to manage the disease by health professionals among community members. 24,35,36,37Because of lack of awareness among affected communities and the insufficient expertise and understanding among medical professionals, FGS is an underreported, misdiagnosed and untreated medical condition. 35,38,39The FGS menace cannot be adequately addressed without adequately equipping different cadres of healthcare workers with the knowledge and tools to diagnose and manage the disease. 24,25,40,41Also, prevention and control of FGS are possible through awareness creation that will enhance early reporting, detection, treatment and chemoprophylaxis from an early age and continue throughout life. 42,43There is an urgent need to improve the knowledge base of the populace and build health workers' competence in early detection, diagnosis and FGS management in efforts that will reduce the burden of FGS in lower-and middle-income countries. 24us, this study seeks to map the evidence on the knowledge and management of FGS to identify the gaps in the literature.The researchers also expect to identify knowledge gaps in the study findings that will inform future studies to advance the understanding of and treatment of FGS in sub-Saharan Africa.

Research methods and design
The study will review publications and grey literature on FGS from 1950 to 2022 in sub-Saharan Africa to map the evidence of knowledge and management among young girls and women.This study is part of a multi-phase research to improve Ghana's FGS knowledge, diagnosis, treatment and management.

Research design
A scoping review on both published and grey literature using the proposed framework by Arksey and O'Malley 44 and Levac et al. 45 and PRISMA Extension for Scoping Reviews (PRISMA-ScR) will guide the reporting of the screening (see Table 1-A2).The framework steps are (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating, summarising and reporting the results and (6) quality appraisal. 44,45Because this research is nested in a multi-phase study that already incorporates stakeholders' input, the researchers will leave out the consultation phase.Two seasoned screeners with expertise in scoping review will carry out the above activities, and any inconsistencies in their responses will be resolved by a neutral screener.

Identify research question
The eligibility for this study was established using the Population, Concept and Context (PCC) mnemonic, outlined in Table 1. 46

Research question
What are the gaps in the literature on knowledge and management of FGS in sub-Saharan Africa?

Sub-questions
• What is the burden of FGS among women of reproductive age in sub-Saharan Africa?
• What is the level of knowledge and awareness affected communities have about FGS in sub-Saharan Africa?• What interventions are implemented to improve case detection and management of FGS in sub-Saharan Africa?

Identify relevant studies
The

Study selection
Three phases will be used to screen for potentially eligible studies.In phase one, one researcher will do a thorough search for eligible papers in electronic resources and export them into a new endnotes X20 library prepared for the study.Deletion of duplicates will be agreed upon and done by co-screeners to clean the library.Using the eligibility criteria created using a Google Form, two screeners will independently screen the abstracts in parallel in this phase.Any disagreements about the article screeners select will be settled by talks among the screeners until an agreement is reached.Lastly, full articles will be examined independently by the two screeners.Any inconsistencies in their responses will be addressed by bringing in a third researcher.To evaluate the degree of inter-screener agreement on the articles chosen for the scoping review, the Kappa coefficient of Cohen statistics will be produced. 47The same technique will be used to screen all publications collected from the reference lists of included studies.Researchers may contact the authors to request the entire text of an article for screening if it cannot be located or is not available through online databases or seek help via the University of KwaZulu-Natal library.
The study's article selection will be reported on using a modified PRISMA-ScR flow diagram, as shown in Appendix 2, Figure 1-A2.

Inclusion criteria
Articles inclusion will be based on the following: • Articles that are written in English between 1950 to 2022.
• Articles reporting on FGS in women of reproductive age.
• Articles reporting on the diagnosis and treatment of FGS.
• Articles reporting on FGS conducted in sub-Saharan Africa.• Articles that are qualitative, quantitative or product of mixed methods.

Exclusion criteria
Article exclusion will be based on the following: • Articles published outside of sub-Saharan Africa.
• Articles not reporting on the knowledge, diagnosis and treatment of FGS.

Charting the data
To gather data from the various relevant articles, a data graphing form will be created using Google Forms.Piloting of the form will be done by the researchers to ensure all relevant information is included.To ensure accuracy and ability to gather all eligible data to answer the study question, the form will be revised as applicable.The researchers will continue revising the form throughout this process until all pertinent information from the listed publications has been extracted.The following information will be recorded on the form as follows: • Author and year of publication.
• Aim of the research.
• The sample size used for the research.
• Research design used.

• Type of diagnosis (forms of diagnosis).
• Type of management.
• Main findings of the study (diagnosis and management of FGS).• Other significant findings.
• The target for knowledge assessment.
• Study design used.

NVivo version 12 (Lumivero, Burlington, United States
[US]) 48 will be employed to extract the themes from the articles included for the scoping review.Descriptive statistics will be used to present some findings using frequencies and proportions and presented on tables, graphs and maps.To gather relevant information, deductive (such as specific features of the eligible publications) and inductive (such as research findings or outcomes) approaches will be used.This will enable the researchers to analyse all included studies' thematic content.Utilising the goal and research question, the researchers will offer a narrative summary of the findings that highlight the key ideas from the publications included.The content of our study is the diagnosis and management of FGS, defined as the methods for diagnosing the disease and the means used to manage the disease burden.

Quality appraisal
The Mixed Method Appraisal Tool (MMAT) 49 will be used to appraise the articles selected for the study by the two screeners.The quality of evidence will be rated as (1) a percentage score of 50% as low-quality evidence, (2) above 50% but equal to 74% as moderate-quality evidence and (3) 75% will represent high-quality evidence.Through this process, researchers will appraise all study types.The MMAT is available in Appendix 2, Table 2-A2.

Discussion
Many strategies are being implemented to reduce the burden and the plight of neglected tropical diseases (NTDs) on affected populations worldwide as an effort towards Sustainable Development Goal (SDG ) 3 and its targets to promote the well-being of all persons. 50These efforts include the planned strategies of WHO NTD Roadmap 2012 to 2020, 2021 to 2030, the Countdown of NTD funded by the UKAID and individual country's masterplan for NTDs. 51,52,53All these efforts are geared towards the control and elimination of NTDs including schistosomiasis.
Despite the implementation of the annual MDA aimed at schistosomiasis control and elimination in endemic areas, the disease burden continues to be high in sub-Saharan Africa 54,55 with FGS worsening the plight among women of reproductive age. 13,27,56,57,58Studies have revealed a multi-disciplinary approach is required to integrate different efforts to eliminate schistosomiasis. 7,34,59Lack of awareness about the disease in schistosomiasis-endemic areas and inadequate knowledge among healthcare workers account for the underreporting and underdiagnosis. 24,35,36,37,38Any neglected tropical disease can be effectively controlled and prevented if healthcare workers have adequate knowledge, skills and tools to diagnose and manage the condition. 40Hence, the implementation of the FGS Accelerated Scale Together (FAST) package to bridge the gap by training different cadres of healthcare workers in some districts. 25e study will explore the evidence on the knowledge, diagnosis, treatment and management of the FGS condition among women aged 15-49 in sub-Saharan Africa from 1950 to 2022.The researchers will include evidence on the knowledge, approaches to diagnosing and FGS management.Therefore, the findings and conclusions derived will assist scholars, policymakers and other parties in informing programme guidelines and ensuring efficient healthcare funding distribution.Additionally, this will contribute to increasing the healthcare system's effectiveness, hence, strengthening interventional and preventive measures for FGS.This study will map evidence of sub-Saharan Africa because of the high burden of the disease in the region, 7 and findings are more likely to be applied to Ghana which is in the subregion.The findings of this review will reveal the gaps in the knowledge, diagnosis and management of FGS, and inform future research in this region.

Strengths and limitations
• This study will use primary studies to map the evidence on FGS knowledge, diagnosis and treatment in sub-Saharan Africa.• This study will draw on both studies that have undergone peer review and unpublished research and reports to address the study's aim.• Only articles published in sub-Saharan Africa between 1950 and 2022 will be included.• Quality appraisal of all articles included will be performed for this review.

Conclusion
The researchers anticipate this study will identify and map the evidence on the knowledge and management of FGS in sub-Saharan Africa.This study will contribute to the literature and direct future research regarding the knowledge and management of FGS.
hence, no consent will be required for the data review.Findings from the study will be disseminated electronically in openaccess peer-reviewed journals and scientific conference presentations.Data charting process 10 Describe the methods of charting data from the included sources of evidence (e.g.calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators.

Data items 11
List and define all variables for which data were sought and any assumptions and simplifications made.8 Critical appraisal of individual sources of evidence

12
If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate). 8

Synthesis of results 13
Describe the methods of handling and summarising the data that were charted.8

Selection of sources of evidence 14
Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram.

8
Characteristics of sources of evidence

15
For each source of evidence, present characteristics for which data were charted and provide the citations.8 Critical appraisal within sources of evidence 16 If done, present data on critical appraisal of included sources of evidence (see item 12).8 Results of individual sources of evidence 17 For each included source of evidence, present the relevant data that were charted that relate to the review questions and objectives.
Synthesis of results 18 Summarise and/or present the charting results as they relate to the review questions and objectives.8

Summary of evidence 19
Summarise the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups.Preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) checklist.

9 20 10 Funding Funding 22 10 Source:
Limitations Discuss the limitations of the scoping review process.10Conclusions 21Provide a general interpretation of the results with respect to the review questions and objectives and potential implications and/or next steps.Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review.Describe the role of the funders of the scoping review.The Joanna Briggs Institute.The Joanna Briggs Institute Reviewers' Manual 2015: Methodology for JBI Scoping Review.Australia: The Joanna Briggs Institute; 2015 Appendix 1: researchers will conduct an all-inclusive search in PubMed and an academic search via EBSCOhost, Scopus, Web of Science, MEDLINE and Google Scholar between 1950 and 2022 for relevant articles.The researchers will work with a subject librarian at the University of KwaZulu-Natal to build a search strategy that will allow us to find all and/or most relevant publications for the study.Boolean 'AND' and 'OR' phrases and Medical Subject Heading (MeSH) terms will be introduced in the search.To collect all eligible research papers, the researchers will use the following keywords: FGS, urogenital schistosomiasis, knowledge, diagnosis, treatment and management.Also, the citation lists of each included study will be examined for relevant studies that would help answer this scoping review question.To search for grey literature, websites of international organisations such as WHO and Centers for Disease Control and Prevention (CDC), dissertations and/or theses, conference proceedings and essential government reports reporting on FGS diagnosis and management in sub-Saharan Africa will be conducted.A pilot search to show this scoping review is feasible as shown in Appendix 2, Table1-A1.
Rationale3 Describe the rationale for the review in the context of what is already known.Explain why the review questions/objectives lend themselves to a scoping review approach.Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g.population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.Describe all information sources in the search (e.g.databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed.State the process for selecting sources of evidence (i.e.screening and eligibility) included in the scoping review.7